| NPI | 1962823153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MS PT5634) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0488) |
| Enumeration Date | 2013-12-15 |
| Last Update Date | 2014-08-26 |